Edmonton Symptom Assessment System:

(revised version) (ESAS-R)

Please circle the number that best describes how you feel NOW: No Pain No Tiredness

0 0

1 1

2 2

3 3

4 4

5 5

6 6

7 7

8 8

9 10 9 10

Worst Possible Pain Worst Possible Tiredness Worst Possible Drowsiness Worst Possible Nausea Worst Possible Lack of Appetite Worst Possible Shortness of Breath Worst Possible Depression Worst Possible Anxiety Worst Possible Wellbeing Worst Possible _______________

(Tiredness = lack of energy)

No Drowsiness

0 0 0

1 1 1

2 2 2

3 3 3

4 4 4

5 5 5

6 6 6

7 7 7

8 8 8

9 10 9 10 9 10

(Drowsiness = feeling sleepy)

No Nausea

No Lack of Appetite No Shortness of Breath No Depression

9 10

0 0

1 1

2 2

3 3

4 4

5 5

6 6

7 7

8 8

9 10 9 10

(Depression = feeling sad)

No Anxiety

(Anxiety = feeling nervous)

Best Wellbeing

4 4

5 5

6 6

7 7

8 8

9 10 9 10

(Wellbeing = how you feel overall)

No __________ 0 1 2 3 Other Problem (for example constipation)

Patients Name __________________________________________ Date _____________________

Completed by (check one): Patient Family caregiver Time ______________________ Health care professional caregiver Caregiver-assisted
BODY DIAGRAM ON REVERSE SIDE

ESAS-r
Revised: November 2010

Please mark on these pictures where it is that you hurt: